Who Can Audit Your Charts and What They’re Looking For

Medicare Prospective Payment System (PPS)

The Medicare Prospective Payment System (PPS) ensures patient access to care. Paying home health agencies 50% - 60% of their claim amount on the basis of one visit guarantees the funds to provide services in a timely manner. Unlike managed care organizations, CMS leaves it up to the provider to determine the amount and type of services necessary for appropriate rehabilitation. Of course such a laissez faire approach to healthcare comes with a hefty price tag, and a side of fraud. The solution is a plethora of organizations, called Medical Review Contractors, ready to audit and recoup funds at the drop of a dime. That dime, of course, is the proverbial "red flag"; any indicator that the home health is partaking in activities outside of the norm.

Each auditing agency serves a different purpose, has different selection criteria and reports to a different department, creating a cross-functional auditing organism within CMS, a branch of the Department of Health and Human Services. The main selection source is claim data in the CMS Data Center. Although each contractor establishes their own baselines and deviations, they all compare provider claim submission trends to the aggregate at least every 6 months, looking for anything out of the ordinary. "Out of the ordinary" can also be a significant change within the provider's own billing trends, such as increases in the average number of claims billed, visits billed per claim or even amounts charged per visit. Every 6 months of claim data is compared to the previous 6 month data block, but also at least to the last 18 months, although CMS likes to see comparisons of data for the previous 3 years. Understanding how home health cares get selected is only half the battle. There are two main areas of focus for chart review. Understanding the focus of the contractor requesting records can help agencies prepare for the audit itself.

Medical Review for Program Integrity

Program Integrity Medical Review Contractors focus on compliance with Medicare coding and coverage rules. This includes Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractors (SMRC), Recovery Auditors and CERT (Comprehensive Error Rate Testing). Each contractor selects their data differently, but the goal is always the same.

Medicare Administrative Contractors

There are 3 MAC's for the home health care industry; NGS, CGS and Palmetto. Previously referred to as Fiscal Intermediaries (FI's), each MAC covers a section of the United States and is responsible for claim selection from the entirety of transactions they process. Generally, MAC's are looking to identify and correct overpayments and underpayments. For a map of areas covered by each MAC, see here

Comprehensive Error Rate Testing

The purpose of this agency is to calculate the CMS Improper Payment Rate, which was 12.1% ($43.3 billion) for the entire Medicare program in 2015. CERT contractors select at random from statistically valid data. May the odds be forever in your favor with these guys. 

Recovery Auditors

Like MAC's, RA's look for improper payments via claims and utilization analysis. The overlapping agenda is attributed to the overload of claims MAC's are responsible for processing and auditing. With over a billion claims a year, CMS has developed the Recovery Auditors Program to supplement the improper payment detection and correction process. MAC's and RAC's coordinate their efforts by sharing the specific claims and providers audited to eliminate duplicate reviews.

Supplemental Medical Review Contractors

CMS directs StrategicHealthSolutions, LLC in conducting the SMRC program. Information about how home health agencies can be selected for review are sparse. One of the methods of selection indicates that part of the SMRC workload comes from identified vulnerabilities of the other review contractors, federal oversight programs and other organizations. The goal however is still identifying and correcting compliance related claims problems.

Medical Review for Benefit Integrity

Benefit Integrity Medical Review Contractors focus on possible fraud, waste, abuse and falsification of records. The ultimate negative consequence of not passing this type of audit is an Office of Inspector General (OIG) investigation followed by incarceration, although most home health cares don't make it to either point. PSC and ZPIC reference at least 3 years of claims history of their zones. There are 7 zones total operated by 5 companies: Safeguard Services (SGS), AdvanceMed, Cahaba, Health Integrity and Under Protest. While Program Integrity contractors focus on provider billing trends, Benefit Integrity contractors use beneficiary billing trends as a starting point of analysis. Data comes from the CMS National Claims History (NCH), but also from MAC's, RA's and other sources. When a ZPIC audit is conducted, all claims from all providers of a beneficiary are reviewed internally. If further investigation is necessary, charts are requested, usually from multiple providers. 

Compliance in Home Health

Passing ADR's is all about maintaining compliance year-round, which becomes easier with the right consultant. TT Medical focuses on maintaining Medicare, Joint Commission, ACHC and CHAP compliance. This way, no matter who is looking at your charts, they're safe.